THE NOTTINGHAMSHIRE CORONERS SERVICE. Andrew McNamara Assistant Coroner, Nottinghamshire The City Ground 16 October 2014

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1 THE NOTTINGHAMSHIRE CORONERS SERVICE Andrew McNamara Assistant Coroner, Nottinghamshire The City Ground 16 October 2014

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3 INTRODUCTION Ancient role (1194: John/Richard I): largely as a tax collector! Retain role as investigator re. finds of treasure Silent witness Quincy Reality can be dramatic (except it s rare to pinpoint death down to the minute)

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5 Local Service All Senior Coroner and assistants appointed but not employed by LAs Notts is largest Coronial jurisdiction in England and Wales: 6252 reported deaths in 2013 Council House base along with all Registration services Senior Coroner: Mairin Casey 10 Assistants Officers Team of witness support volunteers Pay us a visit!

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7 Recent Changes Coroners and Justice Act 2009 Putting the family at the centre of the process Chief Coroner Aim of greater uniformity (JC training) and CC s involvement in recruitment End to appointment of medics unless dual qualified Time limits imposed

8 Responsibilities To investigate all deaths where: The deceased died a violent or unnatural death (e.g. deaths at work) The cause is unknown (e.g. exposure to pathogens such as asbestos) The deceased died while in custody or state detention Prevention of future deaths (may be of particular concern in the context of the workplace)

9 Referral Officers receive telephone calls or electronic referrals (NUH) Early contact with family wherever possible Q s to family regarding occupational exposure to pathogens

10 Investigation I In 90% of cases no autopsy/post mortem examination Autopsy/Post mortem examination Pathologist: improvements in CT scanning likely, in time, to reduce the numbers of extensive invasive autopsies (currently costly) Cultural sensitivities borne in mind but not to the exclusion of all else. That may conclude our involvement OR we can choose to investigate

11 Investigation II Few cases do result in Inquest: 14% nationally and 9.5% in Notts Cause of death established, 3 options: Sign off Investigate Inquest Change from previous position

12 Inquests I Obvious ones in this context: All reportable deaths (i.e. here RIDDOR) Industrial diseases Notts coalfield Significant numbers of COPD sufferers Asbestos

13 Inquests II: the questions What is the function of an Inquest? Who was the deceased? Formal ID necessary When did s/he die? Usually straightforward if someone dies following medical care Where did s/he die? How did s/he come by her/his death And, if the case is one which arises from a death by reason of the involvement of a systemic failing by an instrument of the state then one must also look at the circumstances

14 Evidence Gathering & Reportage Statements & reports from: Witnesses Experts Family Investigating agencies (HSE, ORR, RAIB, AAIB, etc)

15 Hearings Open court: Council House Concerned only with the Four Questions Not about issues of blame Coroner decides the witnesses & poses most of the questions Interested parties can, if they choose, be represented & question witnesses Jurors can also raise questions

16 Evidence Giving If you re new to the process by all means visit first: hearings are held in public Ideally review any statement or notes relied upon prior to going into the box Ensure terminology is explained concisely bearing in mind non-technical audience Stick to answering the question!

17 Conclusions/Determinations No longer verdicts In all cases except suicide/unlawful killing on the balance of probabilities Most likely in the industrial situation are industrial disease or accident, or possibly a narrative conclusion Others: Suicide Unlawful killing Natural causes Open (often used in suicide cases since intention cannot be inferred)

18 Conclusions Must be neutral: cannot be seen to decide either criminal or civil liability Can add a rider to say that neglect, not negligence, contributed to the death (tends to be in care/medical sphere)

19 Prevention Regulation 28 Coroners (Investigations) Regulations 2013 Report to Chief Coroner to prevent other deaths Coroner s statutory duty Bear in mind that it is of a public nature: aim is to spread learning

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21 Deaths in the Workplace CPS HSE 12 months from assumption of primacy ORR RAIB/AAIB/MAIB Problematic: 2009 Act imposed time limits 6 months from death to inquest 12 months longstop failing which Senior Coroner must justify why it has not been concluded

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23 Thank you